The 2003 International Federation for Cervical Pathology and Colposcopy (IFCPC) classification system categorizes the findings of keratosis, erosion, inflammation, atrophy, deciduosis, and polyps under the miscellaneous category. An appreciation of these benign colposcopic findings is essential.

Keratosis or leukoplakia: Lesions that appear white on visual inspection of the cervix prior to the application of acetic acid are termed keratosis or leukoplakia. Microscopy of these lesions reveals a thick hyperkeratotic or parakeratotic surface. Located within or outside of the transformation zone, keratotic lesions are raised and bright white. Leukoplakia is a nonspecific finding and may arise secondary to trauma such as with diaghram or pessary use, human papilloma virus infection or even invasive keratinizing squamous carcinoma. Biopsy is necessary to establish the exact diagnosis.

Erosions and Ulcers: Simply defined, an erosion arises from denuded epithelium which exposes the underlying stroma. Ulcers are deeper and involve the underlying cervical stroma. They may be secondary to trauma, such as insertion of a speculum or from tampon use. The edges of traumatic erosions are sharp and consist of normal epithelium. High grade neoplastic lesions are easily denuded and may appear as a erosions with a peeling, rolled back margins of markedly atypical epithelium. Ulcerations may also result from infectious agents such as herpes virus. The base of the infectious ulcer is necrotic and contains inflammatory debris. Concern always exists that the ulceration is secondary to an underlying invasive neoplasm. Biopsy may be necessary, especially with persistent ulcers or erosions.

Cervicitis: Cervicitis may make Pap interpretation more difficult and less accurate, and make colposcopic assessment more difficult. Cervicitis secondary to trichomoniasis results in coalescent erythematous patches giving a reverse punctation also called a “strawberry cervix”. The mucopurulent cervicitis of chlamydia and gonorrhea is associated with prominent vascularity and hypertrophy of the cervical ectropion. Many authorities recommend diagnostic tests and any indicated treatment before biopsy when any cervicitis (STI) or severe vaginitis is strongly suspected.

Atrophy: Prolonged hypoestrogenization results in a thin, friable epithelium. Iodine staining is negative or demonstrates only partial (stippled) uptake due to a lack of glycogenation of the squamous epithelium. Vascularity is prominent with fine, branching capillaries. The tissue is thin, easily traumatized and petechiae or small submucosal hemorrhages may be present.

Nabothian cysts: Single or multiple, the translucent cysts appear yellow and can be as large as several centimeters. Formation occurs secondary to blockage of mucin secreting endocervical crypts by overlying metaplastic squamous epithelium. Nabothian cysts are always located within the transformation zone. Prominent large vessels are often noted overlying the attenuated epithelial surface of the cyst. On close inspection, the vessels arborize normally and are not atypical (disorganized) in appearance. Nabothian cysts are normal. They do not require any treatment. These vessels do not herald invasive cancer.

Ectopy: Ectopy results from eversion of the squamocolumnar junction onto the portio cervix or in rare cases, the vagina. On gross appearance, the everted columnar epithelium appears velvety red and on close inspection the typical villi of the endocervical mucosa are readily apparent. Iodine uptake is negative because columnar epithelium is not glycogenated. Varying stages of squamous metaplasia may be present throughout the surrounding current squamocolumnar junction or as fine acetowhite islands within the endocervical mucosa. Cervical ectopy is most pronounced in adolescence and the first pregnancy when squamous metaplasia is most active. It is also common with the use of oral contraceptives. It is an entirely normal finding, and does not warrant any kind of diagnostic or therapeutic response.

Deciduosis: During pregnancy, the stroma of the cervix may undergo focal decidual change which appears as a raised plaque or a pseudopolyp. This polypoid surface irregularity with prominent vascularity may mimic a high grade lesion or cancer.

Endometriosis: Implantation of endometrial glands and stroma may be secondary to cervical trauma. Endometriosis usually presents as small blue or red surface nodules, a few millimeters in diameter, located on the portio or in the cervical canal.

Endocervical polyps: Focal hyperplastic growth of endocervical epithelium and stroma results in polyp formation. Polyps arise within the endocervical canal and protrude out the cervical os. Erythema is due to the increased vascularity and inflammation. Squamous metaplasia may occur on the surface of the polyp. Friability and ulceration of the polyp may account for postcoital spotting. Polyps can be neoplastic, and may be the presenting sign of cervical neoplasia or endometrial cancer. They should be biopsied or removed for histologic evaluation.

References

1. Walker P, Dexeus S, DePalo G, et al. International terminology of colposcopy: An updated report from the international federation for cervical pathology and colposcopy. Obstet Gynecol 2003;101(1): 175-7.
2. Apgar BS, Spitzer M, Brotzman GL (eds):. Colposcopy Principles and Practice. An Integrated Textbook and Atlas. Philadelphia, PA, W.B. Saunders Company, 2002.
3. Burghardt E, Pickel H, Girardi F: Colposcopy-Cervical Pathology: Textbook and Atlas. 3rd ed. New York, Thieme, 1998.
4. Reid R, Scaizi P: Genital warts and cervical cancer. VI. An improved colposcopic index for differentiating benign papillomaviral infections from high-grade cervical intraepithelial neoplasia. Am J Obstet Gynecol 1985;153:611.

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